BREAST ONCOLOGY SURGERY

Breast Oncology
Treatments & Procedures

Breast cancer is one of the most common cancers among women in the US, according to Centers for Disease Control. About 1 in 8 American women will develop breast cancer. Dr. Dana Abraham is a breast oncology specialist who offers the highest quality medical treatment available.

Understanding Your Treatment Team

Step 1: Introduction
The shock of a breast cancer diagnosis is often followed by questions about how and by whom you will be treated. Your cancer treatment team will vary depending on the community in which you live and your particular cancer diagnosis. You may be treated in a facility such as a hospital cancer institute or you may go to a combination of different specialists’ offices, diagnostic and surgical centers, and hospitals for treatment. Regardless of the location, a team of doctors will coordinate care and tailor it to you as an individual, and they may meet regularly to discuss your treatment and progress. Fortunately, the majority of breast cancers are detected at early stages, when there are more treatment options available. This animation introduces the roles of cancer treatment team members to empower you with knowledge of what to expect before treatment begins.

Step 2: Primary Care Physician / OB-GYN
People instrumental in making the initial breast cancer diagnosis include the primary care physician, radiologist, and pathologist. Often, the discovery of breast cancer starts with a visit to a primary care physician or obstetrician/gynecologist (OB/GYN). You may report finding a lump or your physician may find an abnormality during a routine clinical breast exam. In these cases, the physician will recommend a mammogram. A diagnostic mammogram or additional imaging may also be suggested if there is a suspicious finding during a routine screening mammogram.

Step 3: Radiologist
Your mammogram and any other imaging tests will generally be performed by a technologist, and the results will be reviewed by a radiologist who specializes in interpreting breast imagery. If cancer is suspected, more imaging and other tests may be requested to help with a diagnosis. In some cases, a specialist known as a breast interventional radiologist may take a small sample of breast tissue, called a biopsy, so that it may be further studied to determine or rule out cancer. In other instances, you may be referred to a surgeon for a biopsy.

Step 4: Pathologist
After a biopsy is performed, the sample will be sent to a pathologist, who is a specialist in diagnosing and classifying disease. The pathologist will examine the tissue sample under a microscope to determine whether or not the sample is cancerous and will report the findings to your primary physician or surgeon.

Step 5: Why a Team?
You may wonder why breast cancer treatment usually involves a team of specialists. The uncontrolled cell growth that becomes breast cancer results from changes in your genetic material (DNA). Therefore each breast cancer is as genetically unique as the individuals in which they occur. Cancer cells start from a single defective cell, but they change as they divide, and the millions of cells that make up a tumor can become different from each other. To target these differences and ensure optimal results, breast cancer treatment may involve surgery, radiation therapy, and medications that prevent cancer cells from growing. In most cases a surgeon, a medical oncologist, and a radiation oncologist will form the core of your treatment team. You may also have the aid of a nurse navigator, oncology nurse, social worker, physical therapist, or rehabilitation specialist for help with coordination, support, and rehabilitation. A reconstructive or plastic surgeon may also join the team.

Step 6: Determining a Primary Contact
Your first step after diagnosis will be to meet with your physician or surgeon to discuss your history, diagnosis, and treatment options. This person may be your primary contact or they may direct you to someone such as a nurse navigator or coordinator who will assist with treatment planning and can direct any questions about diagnosis, treatment, or follow-up to the appropriate specialist. Ask your physician or surgeon if you are unsure if there is someone available to help coordinate care.

Step 7: Navigator/Coordinator
Nurse or patient navigators and oncology nurse specialists are professionals that help people coordinate cancer care. They help with scheduling tests and consultations and can help get answers to questions. The coordinator can also provide referrals for emotional support, educational resources, financial support, transportation, and child care during your treatment. The navigator/coordinator will ensure your information is up to date and shared among the team members and may attend tumor boards, during which specialists meet to review your treatment and progress. The nurse navigator or oncology nurse can also help with survivorship and connect patients and their families to community care resources.

Step 8: Surgeon
Your surgeon will review your diagnosis and history and will help you decide how to best treat the breast cancer surgically. Surgery may take the form of breast conserving surgical procedures or mastectomy procedures in which the breast is removed. For mastectomies, the surgeon will also refer you to a plastic surgeon to discuss reconstruction possibilities. After surgery, your surgeon will assess healing and determine whether additional surgery is needed to get clean, cancer-free margins around the treatment site. At the conclusion of the surgery, the surgeon will refer you to a medical oncologist or radiation oncologist for additional treatment.

Step 9: Medical Oncologist
Medical oncologists are doctors who specialize in treating cancer with medications. These medications include chemotherapy, which works on the entire body to kill cancer cells or prevent them from growing; hormonal therapy medications, which specifically target cancer cells and starve them of hormones they need to grow; or biologic therapy medications, which also target specific cancer cells and disable processes needed for their growth and survival. After discussing your history and treatment options, an individualized treatment regimen for your particular type and stage of cancer will be created. In some cases, cancer medications may be given prior to surgery to help shrink the size of a tumor, which is called neoadjuvant, or before-surgery therapy. More commonly, chemotherapy is given after surgery, in which case it is called adjuvant chemotherapy.

Step 10: Radiation Oncologist
Radiation oncologists specialize in using doses of high-energy radiation to target and treat cancer. Radiation therapy is common after breast-conserving surgical procedures, where it is used to destroy residual tumor cells in the breast tissue. When you meet, your radiation oncologist will go over your diagnosis and treatment options and will determine the most effective form of radiation therapy for your cancer. Treatment may vary according to your age, lymph node status, and tumor characteristics. The radiation oncologist will plan and direct treatments, which are administered by a radiation therapy technologist.

Step 11: Plastic/Reconstructive Surgeon
Plastic, or reconstructive, surgeons are doctors who specialize in performing appearance-altering surgeries. After a mastectomy, the breast mound can be reconstructed, a nipple can be recreated, and the dark-colored areolar region around the nipple can be re-pigmented. Insurance will cover reconstruction as well as surgery on the opposite breast to restore symmetry, if necessary. You can talk to both your general and plastic surgeons about your preferences and options for breast reconstruction either at the same time as surgery or after completion of your treatments.

Step 12: Tumor Boards and Treatment Goal
Depending on the structure of the medical community where you live, your treatment team may meet periodically at a tumor board. At these meetings, doctors from different specialties review patients’ specific treatments and progress. Regardless of the structure of your treatment team, your specialists will tailor treatment for your specific cancer, health condition, and personal decisions. Their goal will be to ensure you receive the best possible treatment to optimize your chances for long-term health.

What is Breast Cancer?

Step 1: Introduction
Breast cancer is a disease in which certain cells in breast tissue grow uncontrollably. A tumor, which may or may not be felt as a lump, can result. If undetected, cancer may spread to other areas of the body, causing harm. With the exception of skin cancer, breast cancer is the most common cancer among women. It is estimated that one in eight women in the United States will be diagnosed with breast cancer in their lifetime. Although advances in treatment have greatly improved survival, it is still the second leading cause of cancer-related deaths among women, behind lung cancer. Other than feeling a lump, there are few signs that breast cancer is developing, so it is important to know about the disease, risk factors, and how to screen for it. Following your doctor’s screening recommendations can help detect breast cancer in early stages before it has spread beyond the breast, allowing more options for successful treatment.

Step 2: Breast Anatomy
Knowledge of breast anatomy can help you to understand where breast cancer originates and how it spreads. The breasts are comprised several types of tissues. Fatty tissue creates shape, connective tissue and suspensory ligaments provide support, while glandular tissue and milk ducts function during milk production. The mammary glands are divided into units called lobes, and each lobe is comprised of many smaller bulb-shaped lobules that can produce milk. Milk ducts connect the lobules to the nipple, where the milk exits when woman is lactating. A network of blood vessels supplies blood to the breast, providing cells with oxygen and nutrients. Lymph, a fluid that surrounds the cells and helps eliminate cellular waste and fight infection, also circulates through the breasts. Lymph is transported from the breasts through a series of lymph vessels that lead to tiny filtering organs known as lymph nodes. Lymph nodes that drain the breast tissues are found in clusters in the underarm region and near the collarbone. They are important in understanding breast cancer because lymph nodes are some of the first sites where cancer spreads, and like blood vessels, they can serve as conduits through which cancer cells can travel to other areas of the body.

Step 3: Cellular Basis of Breast Cancer
Breast cancer, like all cancers, results from changes called mutations in a cell’s genetic material (DNA) that lead to unregulated cell growth and division. Instead of a normal process where cells grow, divide, and die off when they become old or damaged, cells with certain types of mutations behave abnormally. Rather than dying off when they should, they keep multiplying. The excessive growth can form masses known as tumors, which can be either benign or malignant. Benign tumors generally grow slower than malignant tumors. They have more normal characteristics, and tend not to invade other tissues. Since benign tumors don’t spread, they are not considered cancerous. Malignant tumors are cancer. These tumors are characterized by cells with uncontrolled, rapid growth and division that can spread from the tumor site and invade and harm other tissues. Breast cancer, also known as carcinoma, is a general term for various types of malignant tumors that originate in the breast.

Step 4: Types of Brest Cancer
There are two main types of breast cancer. The most common form starts in the ducts and is called ductal carcinoma. The second type is known as lobular carcinoma since it begins in the lobules. When malignant cells form in ducts or lobules but have not invaded the surrounding tissue, the tumors are referred to as “non-invasive’ tumors. These masses are also called carcinoma in situ, a name that refers to a Latin phrase that means “in position.” Lobular carcinoma in situ is often referred to as LCIS or lobular neoplasia. Although LCIS has the word carcinoma in it, it has a low risk of progressing to invasive disease. It’s commonly thought of as a “risk factor” for developing breast cancer, and the risk can be in either breast. Ductal carcinoma in situ (DCIS) carries a much higher risk and, if untreated, could become an invasive form of cancer. A rare form of DCIS, called Paget’s Disease, involves the ductal tissue beneath the nipple and areola. Invasive breast cancers spread from their origin into other breast tissue and possibly to other parts of the body. About 80% of invasive breast cancers1 start in the ducts and are therefore called invasive ductal carcinomas (IDC). Invasive cancer that starts in the lobules, called invasive lobular carcinomas (ILC), account for around 10-15% of invasive breast cancer. Less common forms of breast cancer include tumors that are a mix of both invasive ductal and lobular carcinomas; inflammatory breast cancer (IBC), in which cancer has invaded the skin covering the breast; and rare tumors that originate in the breast’s connective tissues, called sarcomas (angiosarcoma, phyllodes tumor). If the cancer has metastasized, a term that means it has spread beyond the breast, it is referred to as metastatic breast cancer.

Step 5: Breast Cancer Stages
In addition to cancer cell type, breast cancers are often characterized by stage. The staging system for breast cancer helps identify patients who have cancers that behave in a similar fashion. The most common staging system is the TNM classification. The T value correlates to the size of the tumor. The N value describes if the tumor has spread to the lymph nodes and the number of positive nodes. The M value describes whether the tumor has metastasized. The combination of TNM values are used to assign a stage from 0 to IV to the cancer. For example, a stage I tumor might be a small tumor without lymph node involvement that is confined to the breast, whereas stage IV is aggressive, metastatic breast cancer that has spread to other areas of the body.

Step 6: Risk Factors
Certain factors may increase the risk of developing breast cancer. Gender is the primary risk factor. Breast cancer occurs in women at about 100 times the rate it occurs in men7. The chance of developing breast cancer increases with age, previous breast cancer, a family history of breast cancer, and specific gene mutations (BRCA1 and BRCA2 ) that increase the risk for both breast and ovarian cancers. Women who are Caucasian are diagnosed more often than other ethnicities. Those who started menstruation early (before age 12 ), went through menopause late (after 55), had their first child after age 30, or never had children are at increased risk. Actions believed to have preventative benefits include maintaining a healthy weight for your body size, getting plenty of physical activity, and avoiding drinking alcohol in excess. Some people with many risk factors never develop cancer while others with few or no risk factors do. The majority of breast cancer patients have no or few risk factors other than being female and over 55 years of age. There is no definite way to prevent breast cancer, and if you’ve been diagnosed, it’s important to remember that it’s nobody’s fault. The most important factor for improving outcomes is to discover and treat breast cancer early.

Step 7: Signs and Symptoms
Breast cancer often causes no symptoms and even the sensation of pain is uncommon. There are, however, potential signs that may possibly indicate breast cancer. These signs include a lump or thickening in the breast; changes in breast shape, size, or skin characteristics; a scaly rash in the areola; dimpling or puckering of the breast or nipple; or a clear or bloody discharge from the nipple. Keep in mind that other conditions may have similar signs, so it is recommended that you visit a doctor if you notice any changes to your breast.

Step 8: Diagnosis and Treatment
Tests used to detect and diagnose cancer include physical breast exams; various imaging tests, such as mammograms and ultrasound; and microscopic examinations of cell samples. If cancer is found, a treatment plan will be recommended based on the type of cancer, stage, cell characteristics, and individual patient health conditions and preferences. Potential treatments include surgery to remove the tumor and surrounding normal tissue; surgery to remove the entire breast; radiation therapy to eliminate cancer cells; intravenous chemotherapy medications that destroy cancer that may that may have spread beyond the breast; hormonal medications that block the effects of hormones on cancer cells, and immunotherapy treatments that specifically target cancer cells. Clinical trials are also underway to test new or improved therapies to fight cancer. Treatments we use today may change in the future as we learn even more about breast cancer and how to manage it. If you are diagnosed with breast cancer, seek treatment as early as possible. Early diagnosis and improvements in treatment have greatly improved survival and the majority of patients who are diagnosed and treated before the tumor has had a chance to spread will live a normal lifespan.

Breast Self-Exam

Breast self-exams screen for lumps, changes in appearance, or other signs of possible cancer before symptoms arise. Performing breast self-exams is a matter of personal choice. Not all medical organizations agree about the need for regular self-exams, in part because about 80% of lumps that are tested for cancer are determined to be non-cancerous. The American Cancer Society has taken the stance that a breast self-exam is an option for women starting in their 20s.

Step 1: Introduction
Breast self-exams screen for lumps, changes in appearance, or other signs of possible cancer before symptoms arise. Performing breast self-exams is a matter of personal choice. Not all medical organizations agree about the need for regular self-exams, in part because around 80% of lumps that are tested for cancer are determined to be non-cancerous. There is concern that women may undergo unnecessary stress when a suspicious lump is detected. Despite the controversy, a primary argument for breast self-exams is that they promote a woman’s awareness of her body. The American Cancer Society has taken the stance that a breast self-exam is an option for women starting in their 20s. Knowing what is normal can help you identify abnormalities, and early detection improves the chance that breast cancer can be diagnosed before it has spread, allowing more options for successful treatment.

Step 2: When to Perform a Breast Self-Exam
Monthly hormonal variations impact the texture and sensitivity of breast tissue, so it is recommended that breast self-exams be performed at consistent intervals a few days to a week after menstruation has ended. Women using oral contraceptives may want to perform a self-exam each time they start a new set of pills. Women taking contraceptives that prevent regular menstruation or are no longer menstruating should pick a consistent day to perform their breast self-exam each month. If you have had a recent screening, are pregnant, breast-feeding, have implants, have had one or both breasts removed by mastectomy, or have normally lumpy breasts, called fibrocystic breasts, you should still perform regular self-exams to note any new or unusual changes. If you are on hormone replacement therapy, check with your physician for timing recommendations. A monthly breast self-exam takes only a few minutes and involves a visual inspection to look for changes in appearance or unusual discharge and a manual inspection to feel for abnormal lumps or irregularities that may be cause for concern.

Step 3: The Visual Self-Exam
For the visual inspection, stand in front of a mirror looking forward with your arms down to your side, then turn to the left and right. Inspect each breast and your nipples for any changes in shape, size, texture, or skin color as well as signs of dimpling, puckering of the breast or nipple, or a scaly appearance. Use your thumb and a forefinger to check if discharge can be expressed from your nipples. Next clasp your hands behind your head and perform the inspection from the front and at both sides. Finally repeat the visual inspection with your hands on your hips, rolling the shoulders and elbows forward, which tightens the muscles in your chest and may accentuate possible changes. If you have large breasts, raise each breast with a hand and inspect underneath.

Step 4: The Manual Self-Exam
For the manual portion of the exam, raise one arm and place your hand behind your head. Use the pads of the middle three fingers of the opposite hand to move over the breast in small overlapping circles in your preferred inspection pattern. For the vertical pattern, which is considered the most effective, start at one edge of the breast and move your fingers up one row, down the next, and back up again to cover the entire breast. Some women prefer a pattern of concentric rings, working either toward or away from the nipple, or a radial, clock-like pattern moving in each wedge toward the nipple. Select whichever pattern you are most comfortable using consistently. As you perform the exam, slide your hand over to each new area without lifting the fingers and feel with three different pressure levels. Use light pressure to feel tissue closest to the skin; medium pressure for the intermediate region, and firm pressure to feel tissue near the ribcage. Cover the entire breast tissue area, which extends from the collarbone to the fold beneath your breast, and from the breast bone to the midline of your armpit. Also check your lymph nodes in the area between your collarbone and armpit. When complete, repeat the exam for the opposite breast. If the inspection was done while standing, it is also a good idea to examine your breasts while lying down, which helps flatten the breast tissue against the chest and gives better access beneath and to the side of the breast.

Step 5: Findings & Conclusion
Create a mental image of what your breasts look like and how your breast tissue feels normally. If you notice an irregularity, check the other side; if there is symmetry it is less likely to be a matter of concern. Note any visible changes, lumps or knots detected in the breast or armpit, or nipple discharge other than breast milk to discuss with your physician. It is okay to mention what you feel may be a minor change; don’t let the fear of possible cancer deter you from reporting any findings to your physician. Keep in mind that the majority of lumps are not cancerous. The goal of screening is to identify potential breast cancers before they have spread or cause symptoms, when there are more treatment options if a lump is diagnosed as cancerous. Early detection can save lives.

Mammography

Step 1: Introduction
Mammograms are one of the most beneficial tools for breast cancer screening today. Mammography is sensitive enough to reveal a tumor several years before it may be found in self-exams or other clinical exams, which may provide more options for successful treatment. Mammography is a medical imaging technique that uses low energy x-rays to visualize breast tissue. It is generally recommended annually for women starting at age 40, along with monthly self-exams and routine clinical exams. Women who are at higher risk of breast cancer, especially women with a strong family history of breast cancer and women with dense breast tissue, should get screened earlier. Knowing what to expect from your mammogram can help alleviate anxiety, and while recalls occur in about 10% of cases, most breast abnormalities are not cancer.

Step 2: Film and Digital Mammograms
Mammograms are captured either on film or digitally. Film and digital mammography are equally accurate for the majority of women, but for women under 50, who have denser breast tissue, digital mammography has been found to be better than standard film for detecting breast cancer. Digital images may be viewed directly on a computer and the radiologist can adjust the contrast or enlarge certain sections for closer examination.

Step 3: Screening and Diagnostic Mammography
There are two types of mammography procedures. Screening mammography, also called routine mammography, for when no symptoms are present and diagnostic mammography for when an abnormality in the breast is suspected or discovered during routine examination. In a screening mammogram, each breast is imaged individually and two views of each breast are taken: an angled side-view in which the X-rays penetrate the breast from the side, and a top to bottom view. Diagnostic mammography may require additional magnification views and spot compression views, which target a lump or a suspicious area in the breast. In the future, mammography may be replaced by a process called tomosynthesis, a medical imaging system that is equivalent to a 3D mammogram and will help increase detection while reducing recall rates. For now, keep in mind that for the majority of patients asked to return for a diagnostic mammogram, breast abnormalities turn out to be benign, or non-cancerous.

Step 4: Preparation
Your doctor may refer you to a clinic or you may find a certified radiology and imaging center or a mobile mammography van. If you are over 40, you can also schedule a screening mammogram without a doctor’s referral. Be prepared to provide any personal or family history of breast cancer, if you have had breast surgery, or information about past mammograms. If you have sensitive breasts and are still menstruating, you may want to schedule your procedure for the week following your period. Inform your physician if you think you may be pregnant. On the day of your mammogram, do not use deodorants, lotions, powders, or perfumes as the ingredients found in these products may show up as false spots on the X-ray.

Step 5: Procedure
The mammography unit is attached to a device with an x-ray emitter and parallel plates that hold your breast at different angles during imaging. The top plate, or paddle, is adjustable for compression and placement of the breast; the bottom plate records the images and contains a digital or traditional film cassette. Flattening the breast is necessary as it reduces the tissue thickness and helps eliminate areas of overlapping tissue during the mammogram, therefore reducing the X-ray exposure needed for an accurate mammogram. While the pressure may be uncomfortable, it should not be extremely painful and will only last for a few seconds for each view.

Step 6: The Mammogram Image
A mammogram image appears in shades of black, gray, and white. The denser the tissue, the less radiation can pass through the structure and the lighter it will appear on the mammogram. Cancerous tumors and some benign breast conditions are different in density than the surrounding breast tissue and appear as white or light gray masses. Breast tissue loses density over time and generally appears gray on a mammogram. In younger women or women with dense breast tissue, however, breast tissue may appear white or light gray. For women with dense breasts, a whole breast ultrasound may be recommended by some doctors as an adjunct procedure. Ultrasound technology offers no risk of radiation and may help catch smaller cancers when used in combination with mammography.

Step 7: Results and Readings
Results from a mammography reading are typically categorized as negative, benign, probably benign, suspicious, highly suggestive of malignancy, or as a known malignancy. A mammogram can reveal many types of common benign or non-cancerous, breast conditions. Cysts and fibroadenomas are lumps composed of fibrous and glandular breast tissue. Other findings include calcium deposits called calcifications and microcalcifications, which appear as small, bright white spots on a mammogram. A cluster of microcalcifications may indicate ductal carcinoma in situ, or DCIS, a non-invasive form of breast cancer. A cluster of invasive breast cancer cells typically do not have distinct borders and appear to invade the surrounding breast tissue. Not all breast cancers can be detected by screening mammography. Your doctor or the radiologist may recommend follow-up tests including diagnostic mammography, ultrasound, MRI, and if necessary, a tissue biopsy. Try not to worry if you are called back to receive another test; keep in mind that many recalls are due to false-positives and further testing may determine your reading as negative.

Step 8: After Diagnosis
If you have been diagnosed with breast cancer, mammography and other medical imaging technologies are helpful in determining the size of the tumor or whether the cancer cells have spread. Medical imaging can also be used to detect if a tumor is responsive to radiation or chemotherapy treatments, or to test for breast cancer recurrence following surgery. If your doctor suspects that the cancer has metastasized, or spread to other parts of the body, a bone scan or PET scan may be ordered to check for metastatic disease. While there has been some debate about the benefits of mammography, studies show that the advantages of getting regular mammograms outweigh drawbacks of false-positives or risk from radiation exposure. Remember that recalls are common and most breast abnormalities are not cancer. Early detection can save lives and is the most crucial step to treating breast cancer.

Chemotherapy

Step 1: Introduction
Chemotherapy, or simply chemo, is a drug-based cancer therapy. Unlike other breast cancer therapies (hormonal therapy, biologic/immunotherapy, radiation therapy) that specifically target cancer cells or surgically remove the cancer and some adjacent tissue, chemotherapy is unique in that it is a systemic treatment. This means that it works throughout most of the body, making it effective not only for treating a cancerous mass in the breast, but also for cancer cells that may have spread to other parts of the body. New chemotherapy drugs are being developed and studied constantly. This animation will not cover every possible chemotherapy drug and treatment combination, but rather will provide you with an understanding of when and why chemotherapy is used, the delivery process, possible side effects, and other details about what to expect if chemotherapy is part of your breast cancer treatment plan.

Step 2: How Chemotherapy Works
Like all cancers, breast cancer results from changes called mutations in a cell’s genetic material (DNA) that lead to unregulated cell growth and division. Instead of the normal process where cells grow, divide, and die off when they become old or damaged, cells with certain types of mutations become cancer cells, do not die off and instead keep multiplying. Uncontrolled growth can form masses known as tumors, and cancer cells from these masses can invade adjoining tissues or spread to other parts of the body through the blood and lymphatic systems. Chemotherapy drugs work by circulating through your bloodstream and inhibiting or preventing cell growth and division. Since cancer cells divide more rapidly than most healthy cells, chemotherapy drugs are able to weaken them and stop them from continuing to grow and spread. The genetic mutations that cause cells to become cancerous also make them less able to repair cellular damage. Chemotherapy takes advantage of this vulnerability, causing cancer cells to die off, whereas healthy cells can often repair themselves and survive.

Step 3: When is Chemotherapy Used?
Your medical oncologist will determine if chemotherapy is appropriate based on your type of breast cancer, how aggressive or likely the cancer is to return , your age, menopausal status, other planned breast cancer treatments, your general health, treatment history, and whether the cancer has spread to your lymph nodes. Other considerations may involve specific characteristics of the cancer cells. For example, if they are sensitive to hormones, hormonal therapy may be an additional option, and if the cells produce excessive growth proteins, known as the HER2 status, they may be responsive to treatment with specific drugs. Chemotherapy can be useful for all stages of breast cancer. Chemo may be used for what is called neoadjuvant therapy or adjuvant therapy. Neoadjuvant therapy occurs before surgery and may be used to shrink a tumor to make it easier to eradicate surgically. Adjuvant therapy occurs after recovery from surgery and aims to rid the body of any remaining cancer cells, reducing the chance of the cancer returning, called recurrence. The term adjuvant is used because surgical removal is considered the primary treatment. Sometimes chemotherapy is the only treatment, but more commonly it is used in conjunction with surgery, radiation, or both. For advanced-stage breast cancers that have metastasized, or spread to other areas of the body, chemotherapy is used to damage or kill as many cancer cells as possible. Additionally, chemo is used to alleviate symptoms associated with advanced-stage cancer.

Step 4: Chemotherapy Drugs
There are currently over 100 chemotherapy drugs, with more being developed and studied every year. Some of these types of drugs are used alone, called single agent chemotherapy, but many are more effective when used in combination, called a chemotherapy regimen. Drug combinations may be able to target different aspects of growth and division as well as variations among individual cancer cells. Targeting different aspects of cancer cell growth and division also reduces the chance that a new mutation that arises will cause the cancer to become resistant to a particular treatment.

Step 5: Chemotherapy Courses and Cycles
Chemotherapy is given as a course of treatment over several months. The course is broken into to a number of cycles during which you receive treatment and generally have some time to recover before the next cycle begins. For example, you may receive chemo drugs once a week for two weeks and then have a third week to recover before your next cycle begins. Cycles vary from 2-3 weeks to a month or more. Your blood will be drawn often during your treatment for blood cell counts that help assess how well you have recovered and how ready your body is for the next treatment cycle. Some people receive a growth factor that helps their white blood cell counts more rapidly return to normal levels. This strategy is used for what is known as “dose-dense” chemotherapy in which cycles are timed closer together. Courses of treatment and cycle lengths vary considerably depending on the type of drugs used, their interactions, and side-effects.

Step 6: Delivery Methods
Breast cancer chemotherapy is commonly administered directly to the bloodstream in liquid form, though some of the drugs may be given orally as tablets or capsules that you swallow. Be sure to take oral medications exactly as prescribed in order receive the correct dosage and keep your cycle on track. Chemotherapy is usually delivered directly into a vein, called intravenous, or IV, delivery. IV delivery may be done on a visit-by-visit basis using a vein in your forearm or hand or into a central vein in your chest via a catheter that remains for the duration of treatment. In what is called an IV push, a syringe is used to deliver medication over the course of a few minutes. If your chemo is given by what is called an infusion, or slow-drip, a bag connected to the catheter delivers medication over a longer time period. The flow rate is often controlled by an IV pump. Primary forms of breast cancer IV chemotherapy delivered via a central venous catheter are known as portacaths, or simply ports, and peripherally inserted central catheters, or PICC lines. A port consists of the central line catheter connected a small chamber that is surgically inserted beneath the skin. A small needle is used to penetrate a membrane atop the chamber to deliver medication. A PICC line runs from a vein in your arm to a large central vein in your chest. The portion that exits the skin is capped or closed, covered with a sterile dressing, and taped to your arm when not in use. In addition to use in a clinical setting, ports and PICC lines are also used with portable electronic IV pumps for continuous infusions that may last several days. Ports and PICC lines allow fluids to be delivered or blood to be drawn as required for chemotherapy treatment without extra needles. Some versions also allow injection of substances (contrast media) that improve certain types of medical imaging.

Step 7: Side Effects
Although chemotherapy works well on rapidly dividing cancer cells, cells in your bone marrow, hair follicles, nails, and the linings of the mouth, nose, intestine, and vagina also divide quickly. When these cells are affected, side effects can result. Possible short-term side effects, which typically disappear after treatment, can include hair loss, mouth sores, irritation on the hands and feet, nausea, vomiting, or diarrhea. Short-term side effects related specifically to bone marrow can include a lowered red blood cell count, called anemia, and associated fatigue; bleeding or bruising easily due to fewer clot-forming blood platelets; and an increased chance of infection from a lowered white blood cell count. Potential side effects that may disappear after treatment or may persist long-term include numbness, pain, tingling, weakness, or temperature sensitivity in the hands and feet; fatigue; or a general feeling of being unwell. Hazy concentration or memory, often referred to as “chemo brain,” can also occur. Potential long-term side effects include infertility, premature menopause and an associated loss of bone density (osteoporosis), or heart damage. Other rare side effects related to specific drugs may also occur. It’s important to note that some breast cancer patients have very few side effects while others have several, and two people with the exact same treatment regimen may experience very different side effects. Your oncologist or cancer nursing team will educate you about side effects related to your particular drugs. Your specific chemotherapy treatment regimen will be carefully monitored in an effort to limit side effects while providing the maximum therapeutic effect. In addition, anti-nausea drugs and adjustments to daily routines while undergoing chemo may be recommended to help manage certain side effects.

Step 8: Determining the Success of Chemotherapy
People undergoing chemotherapy often wonder how they’ll know if it is working. Physical exams and imaging tests that assess whether the tumor is shrinking can help determine the success of neoadjuvant therapy. For adjuvant chemotherapy, where the tumor has been removed, effective treatment can only be determined by the lack of cancer recurrence over time. Studies have shown that adjuvant therapy can improve survival rates, which is why it is used. If you receive chemotherapy for cancer that has spread to other areas of the body, blood tests, X-rays, and other scans may be used to monitor your progress.

Step 9: Follow-Up & Conclusion
After completing your primary course of chemotherapy, your oncologist will schedule follow-up visits. These visits typically involve a history and physical exam every 4-6 months for the first five years, then once a year thereafter. You will also be recommended to have yearly mammograms or additional screenings based on breast density and other characteristics. Depending on the drugs used for treatment and other factors such as menstrual status, other tests that may include bone density-testing and yearly gynecologic exams may be recommended. New chemotherapy drugs are constantly being studied and the best treatment regimen is unique for each patient; chemotherapy works best when tailored to your particular cancer characteristics and you as an individual.

Radiation Therapy

Step 1: Introduction
Radiation therapy, also known as radiotherapy, is a targeted, highly effective treatment for breast cancer. It uses high-energy radiation to destroy cancer cells.

Step 2: Radiotherapy Indications and Candidates
Radiation therapy is almost always recommended after the breast-conserving surgical procedure known as a lumpectomy. Although the tumor is removed, radiation is used to destroy any possibly remaining cancer cells and has been shown to reduce the risk of breast cancer recurrence by about 70%. Additionally, radiotherapy is also done in cases where tumors cannot be surgically removed; under certain circumstances after mastectomies, particularly when there is a large tumor or concern that the cancer may spread; or if cancer has spread to lymph nodes adjacent to the breast. Radiation is also used to relieve pain associated with widespread cancer in other parts of the body. Radiation treatments usually begin a couple of weeks after the body has had time to recover from surgery and after any chemotherapy a patient may receive. Patients with any stage of breast cancer are candidates for radiation treatment unless they are pregnant, have a disorder that may prevent proper healing, or have had previous whole-breast radiation therapy on the affected breast. Women with breast implants can usually undergo radiotherapy, as may those who choose reconstruction after a mastectomy, but these candidates should discuss options and special planning needs with their treatment team.

Step 3: How Radiation Therapy Works
Radiation therapy delivers high-energy, ionizing x-ray or photon radiation to cells in the treatment area. The radiation damages the genetic material, DNA, inside the cells. Although radiation can damage any cell, it is more effective on cancer cells because they grow and divide rapidly, and they are less organized than healthy cells, which makes it harder for them to repair DNA damage. In this way, cancer cells will eventually become too damaged to properly grow and divide. They die off whereas healthy cells will recover over time.

Step 4: Types of Radiation Therapy
Breast cancer radiotherapy falls under two main categories: the more common external radiation, where radiation beams are aimed at the breast, and internal radiation where the radiation source is temporarily placed inside the breast. External beam radiation, also known as ‘whole breast’ irradiation, uses a device much like an X-ray machine, called a linear accelerator, to deliver a focused beam of radiation. Detailed measurements are made to focus the radiation directly on the treatment area. External beam radiation is also being used and studied for partial breast irradiation in certain candidates. When used to treat only a portion of the breast, radiation is focused only on the tumor site, sometimes allowing higher radiation dose intensities (IMRT) near the tumor while decreasing or eliminating radiation to nearby tissue. Procedural details for external radiation will be presented shortly. Internal radiation, also known as brachytherapy, is a form of partial breast irradiation. Small tubes called catheters, or more commonly today, several catheters that pass through a single-entry tube connected to an expandable device are positioned inside the breast. A radiation source, usually wire with a tip that can emit radiation, is placed in the catheters to deliver radioactivity to tissue that surrounded the tumor. A low dose may be used for a couple of days or a high dose may be used for several minutes. Internal radiation is also sometimes given to conclude an external beam treatment as a supplemental boost of higher-energy radiation. Although radiation treatment generally follows surgery and any chemotherapy, intraoperative radiotherapy (IORT) is an experimental form of radiotherapy that is being studied in some centers. This form of radiotherapy delivers a short, high dose of radiation to the breast either via external beam or internal radiation right after the tumor is removed during a lumpectomy.

Step 5: Simulation Phase
Prior to external radiation treatment, you will undergo a simulation process where your position and the breast area are mapped to precisely target the radiation. X-rays from multiple angles, known as a computed tomography or a CT or CAT scan, will be taken to accurately target the treatment area. These measurements determine the optimal angles to deliver radiation while attempting to avoid the heart, lungs, and tissues that do not need treatment. Once the simulation is complete, ink marks or small tattoos are made so that you can be aligned in the exact same position for every treatment.

Step 6: Treatment Phase
Before beginning radiation, you may be requested to refrain from using lotions, fragrances, and antiperspirants near the treatment area because they can interfere with the treatments. Once you are positioned, the radiation therapist will typically leave the room and start the treatment. You will be instructed not to move and the linear accelerator will rotate around you to deliver treatment; you will not actually see or feel the radioactive beam. External radiation durations vary by specific patient needs but typically involve a 10-15 minute treatment five days a week for around 6 ½ weeks. Some patients qualify for a shorter course such as 16 total treatments. Each appointment usually takes about a half hour, and many patients find they can continue their normal routines during the course of therapy. You will meet with your radiation oncologist about once a week to check on progress and address any side effects during the treatment period. At the end of radiation therapy, a supplemental treatment known as a boost may be given. A higher radiation dosage is focused specifically on the treatment site using either internal or external radiation. The boost is done as an additional assurance to prevent cancer from recurring in the breast.

Step 7: Possible Side Effects
Radiotherapy may cause side effects, which usually begin about half way through the therapy. The most common side effects are temporary skin irritation near the treatment site and fatigue. Radiation passing through your skin can cause the breast or underarm region to become pink or red, like sunburn, with similar symptoms of itching, soreness, and possible blistering or peeling. These symptoms typically subside within a month and a half after treatment. Mild to moderate fatigue can be expected for most breast radiotherapy patients while the body is healing. You may feel tired for a few weeks to a few months after treatment, but will usually be able to maintain a normal work schedule. Other, less common side effects may affect breast tissue and include swelling or tightening that can affect breast size, enlarged skin pores in the treated area, skin sensitivity and texture changes, or slight discoloration. Changes to breast tissue usually subside within 6 months, but may last for a year or more after treatment. In general, the risk of side effects increases with the size of the treatment area and when lymph nodes are irradiated. Irradiating lymph nodes increases the risk of swelling down the arm known as lymphedema. Lymphedema is usually temporary but it can be permanent and may occur many years after treatment.

Step 8: After Treatment - Summary
After your radiotherapy treatment ends, you will continue to have follow-up appointments and diagnostic X-rays to check for recurrence. These appointments become less frequent the longer you’re cancer free. As you’ve learned, radiotherapy is useful for breast cancer at any stage, reduces the risk of breast cancer recurrence, and can help control the spread of breast cancer. The ability to prevent the rapid growth and division of cancer cells while healthy tissue heals and returns to normal is a powerful addition to your breast cancer treatment options. These benefits generally far outweigh the risk of side effects and most patients are very happy with the outcome of radiotherapy.

Breast Cancer - Surgical Options

Surgery is often the first treatment after a breast cancer diagnosis. In addition to removing cancer from the breast, surgery may also include a tissue sample of the lymph nodes under the arm. The particular surgical procedure performed will depend on the type of the cancer, the tumor size compared to the rest of the breast, and the tumor location. This animation provides an overview of various types of breast cancer surgeries ranging from breast conserving therapies to complete removal of the affected breast; your surgeon will discuss specific options that are available to you.

Breast oncology surgeries come in a few varieties. For example, breast-conserving surgeries include lumpectomies, while breast-removing surgeries include total (simple), skin-sparing, nipple-sparing, and radical mastectomies. The type of surgery you receive depends on several factors, such as the size and location of the tumor and the type of cancer you have. Your surgeon will discuss your options with you to find the best procedure for your situation.

If you have invasive breast cancer, your surgery may also include the removal of one or more of the lymph nodes located under your arm for testing. This procedure is called a sentinel node biopsy. More radical surgeries do not guarantee a higher survival rate or a lower chance of the cancer returning.

Lumpectomy
The most common breast surgical procedure is a lumpectomy, or removal of a lump. A lumpectomy is a breast-conserving surgery that is also known as a partial mastectomy, a wide local excision, or a segmentectomy.

In a lumpectomy, the cancer is removed from the breast, along with a margin of healthy tissue that surrounds the tumor. The tissue removed from the test is then tested to see if the cancer has spread to the margins of the lump area and/or the lymph nodes. If the testing reveals that the margin of the removed tissue is cancerous, a larger lumpectomy or a mastectomy may be performed. Radiation may be applied after a lumpectomy to reduce the chance of the cancer returning.

A lumpectomy is typically an outpatient procedure, so you will be able to return home after the surgery. It is often performed under general or local anesthesia. In about one to two weeks, patients are typically able to return to normal activity.

Mastectomy Procedures
A mastectomy involves the removal of the entire breast, as well as some skin and, on occasion, the nipple, areola, and/or lymph nodes. These procedures are typically performed under general anesthesia and often require one to three days in the hospital. Patients are usually able to return to normal activity after two to four weeks after a mastectomy.

Total Mastectomy

A total mastectomy, which is also known as a modified radical mastectomy, is the most common mastectomy procedure. It typically includes a sentinel node biopsy for testing of the lymph nodes.

Simple Mastectomy

When testing of the lymph nodes is not required, the procedure is called a simple mastectomy.

Skin-Sparing Mastectomy

When there are no cancer cells present in the skin of the breast, a skin-sparing mastectomy may be performed. A skin-sparing mastectomy removes the entire breast, nipple, and areola, but preserves the skin so that a breast reconstruction procedure can follow.

Nipple-Sparing Mastectomy

In cases of smaller early-stage tumors that are not near the nipple, a nipple-sparing mastectomy may be performed. This procedure also requires that there be no cancer cells present in the skin, the nipple, or the lymph nodes under the arm. The nipple and areola are left intact, and some breast tissue is left under the nipple to encourage blood flow and nerve supply to the area. The skin is also preserved so that a breast reconstruction procedure can follow.

Not everyone is a good candidate for a nipple-sparing mastectomy. There is a slightly higher chance of cancer recurrence because of the breast tissue left behind to support the nipple. This procedure can also lead to discoloration or loss of sensation in the nipple. Your surgeon will discuss your options with you and advise you on the best procedure for your circumstances.

Radical Mastectomy

A radical mastectomy removes the entire breast, lymph nodes under the arm, and portions of the chest muscles. This procedure is only performed when cancer is present in the muscles of the chest wall.

Mastectomy Side Effects

Side effects of mastectomy may include numbness around the incision site. A buildup of fluid called a seroma may also occur and can be removed at a follow-up appointment with your surgeon.

If lymph nodes were removed, you may experience a temporary burning sensation under the arm. You may also experience lymphedema, or swelling of the arm, depending on how many lymph nodes were removed.

Breast Reconstruction

Women who have lost one or more breasts to cancer may desire to have their breasts reconstructed. Reconstruction may be done at the same time as the breast is removed via mastectomy (immediate reconstruction), and is often covered by insurance. A variety of reconstruction options exist and can restore breasts to near normal shape, size and appearance. The type of reconstruction you choose will depend on your body type, lifestyle factors, procedure risks and personal preferences. Your surgeon will help you decide which procedure is best for you.

If you undergo a mastectomy procedure, a breast reconstruction procedure can often be performed immediately after. Breast reconstruction procedures are performed under general anesthesia and can take up to several hours.

Reconstructing the Skin
Flaps of skin from your body may be used to reconstruct your breast. Pedicle flaps retain the muscle tissue and blood vessels from where they were harvested, while free flaps are detached from the body and re-attached to the breast area using microsurgery.

There are several different types of breast reconstruction surgery involving the use of tissue flaps.

Abdominal

The TRAM (transverse rectus abdominis muscle) option may be performed as a free flap or pedicle flap procedure. In a TRAM procedure, an oval-shaped flap is taken from your lower abdomen. If it is a pedicle flap procedure, the flap is tunneled under your skin to your chest to create a new breast mound. If it is a free flap procedure, the flap is removed from the abdomen and attached to the breast area using microsurgery.

The DIEP (deep inferior epigastric perforator) option is a free flap procedure. This flap gets its blood supply from the deep inferior epigastric artery and vein. Microsurgery is used to attach blood vessels in the flap to blood vessels in the chest.

The SIEP (superficial inferior epigastric perforator) option is a free flap procedure. This flap gets its blood supply from the superficial inferior epigastric artery. Microsurgery is used to attach blood vessels in the flap to blood vessels in the chest.

Buttock

The SGAP (superior gluteal artery perforator) option is a free flap procedure. The flap is taken from the upper buttock. Microsurgery is used to attach blood vessels in the flap to blood vessels in the chest.

The IGAP (inferior gluteal artery perforator) option is a free flap procedure. The flap is taken from the lower buttock. Microsurgery is used to attach blood vessels in the flap to blood vessels in the chest.

Back
The lat (latissimus dorsi) option is a pedicle flap procedure. The flap is taken from the upper back. In this procedure, skin, muscle, and fat is moved to the chest to recreate the breast.

Synthetic & Harvested
In some cases, synthetic mesh or tissue harvested from another person may be used in a breast reconstruction procedure. When tissue is used from somewhere else, the cells are removed to prevent your body from rejecting the tissue and to prevent the transmission of diseases. This is called an acellular dermal matrix.

Mesh and acellular dermal matrices may be used to support the breast implant within the body or to help repair the affected tissues, including at the site of a flap removal.

Breast Implants
Flap reconstruction procedures may involve the use of implants. Breast implants may also be inserted without a flap reconstruction procedure. Radiation therapy may make it more difficult for a breast implant to be successful. Your surgeon will discuss your options to find the best solution for you.

Single-Stage Implant Reconstruction
Breast implants can be inserted immediately after a cancer-removing surgery. For example, an implant may be inserted after a skin-sparing mastectomy is performed. This is known as a single-stage implant reconstruction.

Two-Stage Implant Reconstruction
A two-stage implant reconstruction involves the use of an expander. This procedure is done when the mastectomy procedure has left the skin flat and tight on the chest. First, an expander is inserted into the breast. Over the next several weeks, it is injected with saline solution through a tube to gently expand the skin. When the skin is sufficiently stretched enough to accommodate an implant, the expander is removed and replaced with a permanent implant. In some cases, the expander is left in the breast as the permanent implant.

In a breast implant procedure, an incision is made in the chest. If a mastectomy was performed previously, the incision will typically be made along the scar. A pocket is made to hold the implant. If the breast reconstruction involves a pedicle flap, the flap will be tunneled underneath the skin and positioned at the breast. The incision is then closed.

Recovering from Breast Reconstruction Surgery
The length of your hospital stay after breast reconstruction surgery varies based on the procedure you undergo. Most breast reconstruction patients remain in the hospital for a week or more. Bruising and swelling is normal and may occur for anywhere from a few days to a few months.

In nearly all breast reconstruction procedures, drainage tubes are used at each incision (the affected breast and the flap site) to prevent fluid buildup as you heal. These are typically removed a few days after your surgery. If your surgeon used non-dissolving sutures, these will be removed within two weeks.

While scars from breast reconstruction surgery do not disappear completely, they do fade considerably over time. Your breast will not retain its previous sensitivity because certain nerves must be cut in order to perform breast reconstruction.

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